The Roots of Peer Review

Nurse Leader Insider, September 21, 2017

Medical staffs have been peer reviewing their cases for decades, and as fellow professionals, we must hold ourselves to the same high standards. Nurses are professionals who must hold each other accountable and evaluate patient care so we can eliminate system and human errors. Nurses are no different than physicians in this way.

An early crusader for quality improvement, E. A. Codman helped develop the concept of outcomes management in patient care. He was a proponent of peer review and quality programs for healthcare delivered at the hospital level.

Practicing in the early 20th century, Codman was a founder of the American College of Surgeons and its Hospital Standardization Program. Eventually, that program would morph into what we know today as The Joint Commission. His statement from 1916 calling for review and transparency are as relevant today as they were a hundred years ago:

I am called eccentric for saying in public that hospitals, if they wish to be sure of improvement, must find out what their results are, must analyze their results to find their strong and weak points, must compare their results with those of other hospitals, must care for cases that they can care for well and avoid attempting to care for cases which they are not qualified to care for well, must welcome publicity, not only for their successes, but for their errors. Such opinions will not be eccentric a few years hence.

—E. A. Codman, A Study in Hospital Efficiency, 1916

Codman would likely be happy to see today that the practice of physicians reviewing the work of other physicians—peer review—is a common practice and is considered to be a crucial element of ensuring that quality medical care is provided to patients.

That element is just as crucial in the nursing profession. The major reason for implementing a peer review process is to improve patient care. If nothing else, peer review is the right thing to do to protect the patient from potential harm. It is just a matter of time before external accreditation agencies, the government, and your hospital will require a formal peer review process of nurses.

More and more, healthcare organizations are required to be transparent about quality performance metrics. While the information that is publically reported is aggregate data, it is important for the healthcare organization to know person-specific performance data so that they can drive improved patient outcomes.

Typically, the outliers or underperformers are a small number of nurses who may not know they are not performing to the standard of care. It is important to give them specific and periodic performance feedback so that they can adjust their care model. Additionally, providing performance data to nurses helps them understand where they rank among their peers. When doing so, it is important to report the data in an anonymous way so that each nurse is uniquely identified using a coding system. This can be useful when metrics are performance based and specific in nature. Transparency is the way of the future, and moving in that direction will help the nursing infrastructure catch up with performance models used by physicians.

The goals and benefits of peer review include:

Improving the quality of care provided by individual nurses

Monitoring the performance of nurses

Identifying opportunities for performance improvement

Identifying system-wide issues

Identifying educational needs of nurses

If the process of peer review is to be effective, then a formal structure must be created to allow for the tracking and trending of information and the identification of potential system or human failures. Case review is useful for this, as it presents opportunities to identify failures through investigation so nurses and other team members can correct them before injury occurs in another patient or patients.

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